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(Cross-posted at The Makeshift Academic)

Here's the thing about the individual mandate in the Affordable Care Act: Everyone loves to hate it.

The mandate is a critical part of the ACA. If you want to mandate that an insurer universally issue policies all applicants at similar prices regardless of pre-existing conditions, you have to prevent healthy people from free-riding outside the system until they get sick. If only sick people purchase insurance, premiums may go up and spiral out of control. By inducing healthy people into the insurance pool through a mandate to purchase health insurance, we can lower overall costs and keep insurance affordable for everyone.

And yes, empirical research suggests that individual mandate will come in quite handy in persuading healthy people to buy insurance, as this New England Journal of Medicine study suggests.

Conservatives hate the mandate because they argue that it violates people's freedom not to buy a product. I suspect that many of them also object to it because it makes rich and healthy people ("makers", "job creators" "real Americans") pay insurance premiums that will benefit poorer and sicker people ("takers," "moochers" "the 47 percent.")

Or maybe they just hate it because a group of center-left reformers embraced it after Conservatives first introduced the idea.

Some liberals in turn hate the mandate because they think makes people give money to evil insurance companies for lousy products. I also suspect that they find the mandate's narrative emphasis on "personal responsibility" a bit off-putting when they feel that the major idea is creating a universal right to health care.

For more, follow me below the jump.

I don't really have much to say to the Conservative point of attack beyond rejecting it, except for the fact that the logic in use here undermines the entire idea of insurance risk pools and ignores the spillover effects that sickness can have on other members of the community. (Repeat after me: No man is an island; now please get your damn vaccinations and get screened for STDs). I also emphasize that this view of the world pretty much kicks anyone with a health problem to the curb as a useless piece of junk, which not only is incredibly cruel, but also a tremendous waste of human talent. (I mean, this guy has probably run up a few doctor's bills in his time, but I'm kind of glad UK taxpayers chipped in to take care of those.)

But I have a more nuanced view of several left-of-center objections to the mandate -- though I disagree with them.

Perhaps the discomfort with "individual responsibility" as the narrative is understandable when we all feel that getting people the ability to have access to health insurance and health care is the primary purpose of a law. After all, it's not like poor people don't get health insurance because they are irresponsible; they don't get it because they can't afford it.

So I can forgive one of my friends (who I suspect does know better) who once argued that Obama should delay the individual mandate to compensate the little people for to delaying the employer mandate that presumably benefited the big shots. But if you don't like the narrative justifying a good policy, change the narrative -- don't abandon the policy.

The second reason many progressives hate the mandate -- or a least the major push-back I've gotten in correspondence -- is that it requires us to pay insurance companies money.

But here's the thing: U.S. law now greatly restricts private health insurance companies  under the ACA in ways that it didn't before.

It's true that restrictions aren't as tight as they are in other countries with an individual mandate, like Switzerland (which actually has a tougher mandate -- you pay a fine more expensive than the average policy, while in the United States you pay a small percentage of your income, capping out at roughly $600, which is considerably less than the annual cost of a policy.) However, the restrictions we have here will approximate that. Insurance companies can still make a profit on their product, but new regulations limit that profit in four ways. First, by mandating a medical loss ratio of 80 to 85 percent for insurers (meaning they have to spend at least that percentage of their premium revenue on reimbursing medical expenses) Second, insurers can't turn anyone away because of pre-existing conditions. Third, there are strict limits on their ability to charge differing classes of people different rates (for example, ending gender discrimination in rate setting). Finally, every package must have a standard set of included benefits -- including free preventative care and family planning services.

I'm not arguing that insurance companies have seen the light and don't want to screw over patients to make money. However, the ACA drastically curtails their ability to do so.  One goal for progressives should be to improve these measures  -- for example, creating federal mandates for tighter regulations in state insurance markets.

I'm also not arguing that the ACA is perfect (it's got some big flaws), and I would like to see a public option or the ability to buy into Medicare or Medicaid -- which is another sort of public option -- among other things in future reforms.

The final point I leave you with is that many progressives see a single-payer system as the ultimate goal. I would be quite happy with this outcome.  But remember, single-payer systems have the strongest individual mandate of all: everyone is required by law to pay the taxes that fund health spending.


What are your thoughts on the individual mandate?

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| 49 votes | Vote | Results

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Comment Preferences

  •  Well, let's put it this way. (0+ / 0-)

    The individual mandate is unenforceable and, in fact, there is no mechanism to enforce it. While local governments do have the option of enforcing the collection of property taxes by taking the property and selling it for non-payment, the feds have no such power even over income taxes. We don't have debtor's prisons and it's not possible to squeeze blood from a turnip.
    Our whole income tax system is based on voluntary compliance. The only thing people get caught on is perjury or fraud for making false reports. This really frosts Republican authoritarians. They came up with the individual mandate because they want government to be in the business of mandating or coercing individual behavior.
    The structure of government set up by the Constitution mandates that public officials carry out duties and obligations. The cons aren't capable of doing that. They don't do obligations; they issue orders. That government should provide for the general welfare throws them for a loop. They don't know how to take care.
    So, they agitage over the mandate because it freaks them out.

    •  Yeah, except when they snatch your tax (0+ / 0-)


      At that point, it's kind of enforceable.

      "But the traitors will pretend / that it's gettin' near the end / when it's beginning" P. Ochs

      by JesseCW on Tue Oct 29, 2013 at 03:05:40 PM PDT

      [ Parent ]

      •  People without taxable income don't file. (0+ / 0-)

        It is a matter of historical fact that a million people each year had tax withheld from their earnings and could get the money back, if they bothered to file. But they don't.
        There is always an interest in getting more people into the system, but some people apparently care more about their time than money.
        That's very bothersome to the money-obsessed.

    •  There is and has been an individual mandate (3+ / 0-)
      Recommended by:
      JamieG from Md, Fake Irishman, hannah

      in effect in Massachusetts for a number of years, we have 97% compliance.  

      If a person is employed by a business that offers health insurance, for the person to decline requires that the employer submit a HIRD form that must be completed by the employee and sent to the Commonwealth.  You can decline employer coverage if you are covered by a spouse, for instance, but if you have no other coverage, you have to complete the HIRD form (required by your boss) that indicated the least expensive coverage you would have been qualified for that you refused.  IF the employee can afford the coverage but refuses, then penalties incur.

      At least in Massachusetts, it's not as easy to avoid penalties just because you don't file taxes.  Your employer is now engaged in the mix and reports your non-compliance.  

      What is surprising to me is how normalized getting health insurance coverage from the Connector is for young people in Mass, now.  How normalized that expectation has become.  I work in a business that has at least 50% of its staff under 30, and they all have health insurance coverage, and they seem happy to get their teeth fixed, and their ailments seen.  It's a sea change from when I was young, but it's happened here, and I think it's just a matter of time, nationally.  

      "Out of Many, One Nation." This is the great promise of the United States of America -9.75 -6.87

      by Uncle Moji on Tue Oct 29, 2013 at 05:17:53 PM PDT

      [ Parent ]

      •  I live in Ma. until last year when our Governor (0+ / 0-)

        capped the rate that insurance companies could raise their rates to single digits, my premium increased by double digits each year since our mandated healthcare was implemented. With the cap it went up by 9% last year. My benefit packet this year shows a 6% increase for next year with 1.25% of it forACA fees and the remainder inflationary and usage fees.
        So I've average double digit increases for the last  7 years.
        Though it appears as if the rate cap may have slowed to single digit. ACA is also forcing a change to my vision plan so that is another few bucks a month more.

        So this England resident disputes the New England Journal of Medicines opinion on mandated coverage lowering costs .

        •  A question (1+ / 0-)
          Recommended by:

          Would the rate increases have been lower without the individual mandate? There are many things that drive up rates.

          •  Here is one related article that I've found (0+ / 0-)
          •  Context (0+ / 0-)

            Here is a link from the 2012 Kaiser Foundation survey on actual average out of pocket employee costs for family coverage premiums and actual average out of pocket cost to employers for premiums in all 50 states plus DC.  

            Kaiser Survey

            If you read the chart you can see that in 2012 Alaska, DC and Massachusetts had the highest per employee premium costs for family coverage (and only Mass has the individual mandate, not Alaska or DC) each topping over $17K per employee family covered, but with Florida, Louisiana, Miss, Rhode Island, So Dakota, and Virginia each charging their employees more on average for per person family premium coverage than Alaska, DC or Mass.

            I don't think that you can substantiate a claim that correlates either total premium increases or individual out of pocket premium increases to the individual mandate.

            "Out of Many, One Nation." This is the great promise of the United States of America -9.75 -6.87

            by Uncle Moji on Tue Nov 05, 2013 at 08:57:18 AM PST

            [ Parent ]

        •  Do you know what the actual rate of (0+ / 0-)

          increase has been in Mass in the years before Romney care?  I worked in the HR industry and the average annual  rate of increase charged to businesses that provided health care for premiums was about 25% per year.  So, 6% or 9% increases actually reflect a slowing trend on the rate of increase when viewed over a longer term.  And most large corporations would be thrilled to accept that kind of rate of increase.

          The insurance my old company offered was considered excellent (we were in a highly competitive area and our benefits package was essential to our market), and we did not offer vision plan.  That you pay for vision care for a "few bucks a month more" is for a kind of coverage that most private employers do not offer, for any sum.

          While I can appreciate that no one likes an increase in premiums, I think perspective is helpful.  

          "Out of Many, One Nation." This is the great promise of the United States of America -9.75 -6.87

          by Uncle Moji on Tue Nov 05, 2013 at 08:29:03 AM PST

          [ Parent ]

  •  There are options to the mandate (2+ / 0-)
    Recommended by:
    Fake Irishman, gramofsam1

    I feel that there are options to the mandate that were never properly explored:
    1. the idea that only sick people buy insurance, is not really proven. In reality, prudent people buy insurance. Prudent people also eat right, exercise and avoid risky behaviors.

    2. the 90 day waiting period already prevents people from buying insurance when they get sick. This could be expanded to be 180 days for a pre-existing condition. For example- if you broke your leg and then try to buy insurance, then the insurance will start kicking in after 90days, EXCEPT for your leg- it won't start kicking in until 180 days later.  This will bring severe pain on those free-loaders.

    3. Anyone going without insurance will need to post a $20,000 bond per head with the government (kind of like car insurance in some states). When you end up in the ER, and can't pay your ER bill, the hospital can claim from this bond. If and when you decide to buy insurance, this money will be returned to you. The good thing about this is- the government gets to sit on a sizeable pool of slush fund that could be used to fund Medicaid, etc.

    4. A similar system as Medicare. If you join Medicare at age 65, you lock in the lowest premium. For each year you delay, your lock in premium will go up. So any young healthy person who wants to delay getting coverage- will see their rates go up, when they decide to get coverage.

    5. Have non-profit co-ops in every exchange. This was actually in the ACA bill that was passed. But unfortunately, the funding for the co-ops was gutted through the various budget battles.

    6. People who pay the fine instead of getting covered, get swept into very, very high risk, bare bones, low coverage plans.  So at least they get 'something' for their money. The insurers also get to maintain a relationship with these people, and get a chance to 'upsell' to these customers as time goes on.

    •  here's a better idea . . . . (0+ / 0-)

      Make health care a public utility, just like cops and fire departments. When people get robbed, we pay cops to catch the thief. When people's house catches on fire, we pay firemen to put out the flames.  When people get sick, we should pay doctors to make them well.

      Remember when that used to be the progressive program?

      For example- if you broke your leg and then try to buy insurance, then the insurance will start kicking in after 90days, EXCEPT for your leg- it won't start kicking in until 180 days later.  This will bring severe pain on those free-loaders.
      And in the meantime, the guy with the broken leg does what, exactly.  

      You're all heart, aren't you.

      Maybe we should check his immigration status before we treat him, too . . . ?


      •  In other words... single payer (1+ / 0-)
        Recommended by:
        True North

        Everyone pays taxes to a public "utility" that takes care all of the bills -- like Canada or the UK.

      •  I agree with you in principle (0+ / 0-)

        As Obama said, if we were starting from scratch, single payer would be the way to go. But we are not starting from scratch. Hence this kludgey public-private thing. And when you have a public-private ting you need to make sure nobody is freeloading. The mandate, and everything I discussed as alternatives to the mandates, are all different ways of stopping the freeloaders.

        •  I don't care about the "freeloaders" (0+ / 0-)

          Everyone has the right to health care, simply by virtue of having been born.  Perhaps I'm just not as heartless and cruel as the Libertarian loonies seem to be.

          We don't need to start from scratch.  We already HAVE a national health care system that has provided excellent care for over 50 years, without any problems or difficulties.  We call it "Medicare", and all it would take is a single-line bill to make everyone in the US eligible for Medicare from the time of birth.

          End of problem.

    •  Some interesting ideas here (0+ / 0-)

      No. 6 is actually a variation of Switzerland, where you automatically get enrolled in a plan in some cantons.

      Some of these things aren't directly relevant to the mandate. For example, the co-ops are just offering other insurance plans -- that in itself might not get other people to enroll.

      No. 2 seems a bit cruel, and it opens the door to abuse.

      No. 1 is reasonable, but the point isn't that all people who aren't sick don't buy insurance, it's just that they have a higher probability of not buying it.

  •  here's my gripe------the mandates don't change the (1+ / 0-)
    Recommended by:

    actual insurance that is available. And that insurance STILL does not allow poor people to see a doctor when they need to.

    Virtually all of the low-end plans in the ACA are shit insurance with high deductibles ($2-4000 seems to be typical). When you go through the policies listed for sale at all the ACA websites, take a gander at the deductible (the part that YOU have to pay, completely, before the insurance company gives you one thin dime) for all the policies that you can afford with your subsidy. Then picture yourself as a low-wage worker (either just above the Medicare cutoff or in a state with no Medicare expansion) who just broke her leg or just developed a persistent cough----and ask yourself how the hell you are going to pay that deductible.

    (And that leaves aside entirely the fact that most of the policies don't even pay the entire bill after the deductible--theyt pay 60% or 80% or whatever, up until you reach your "maximum out of pocket" for the year--which seems to range around $6-8k or so, an amount that is simply unaffordable for most.).

    Most of the insurance sold under ACA is still shit insurance, and it still guarantees that many people who need to see a doctor won't, because they still can't afford to pay the deductible. Even if we pay their premiums 100% for them, low-wage workers still won't be able to afford to pay the deductible. Which means they either don't get care when they need it, or they don't pay for it.

    That is NOT how insurance is supposed to work.

    If our goal is really to let people get care when they need it, then there are only two possible fixes--either we pay their deductible as well as their premiums, or we eliminate deductibles entirely in any insurance plan sold through ACA.

    •  There is no deductible (0+ / 0-)

      For regular Dr. Visits such as physicals.

      If you are against sane gun regulations then by definition you support 30,000 deaths a year by firearms.

      by jsfox on Tue Oct 29, 2013 at 02:42:32 PM PDT

      [ Parent ]

      •  so what. it's not "regular dr visits" that make (1+ / 0-)
        Recommended by:

        people go broke---it's breaking your leg and not having the money to pay the deductible plus the 20-40% of the bill that your much-vaunted insurance doesn't cover.

        •  uh, you don't seem to really understand the (3+ / 0-)

          insurance policies or terminology that you are making an argument about.  Reasonable.  Most people who have health insurance coverage don't understand it.  But if you are going to make a claim about the horrible nature of a deductible, you ought to understand what a deductible pertains to and what it does not.  

          It's terribly arcane and people often conflate a required co-pay that is used toward a deductible as evidence of non-coverage, say for an ER visit that turns into an admitted hospital stay.  I have a $2K deductible but I paid only $300 for my entire event, including ER visit, overnight in the Cardiology unit, and the battery of cardio tests the following day. The actual cost of my event to my insurer was significantly higher than my out of pocket costs, even with my high deductible, since I paid only $300 toward my 2K deductible.

          You might wish to do a little more research before making as strong a statement about what isn't covered (before or after co-pay or deductible).  I agree with your lack of fondness for insurance companies but you ought to at least have your facts in order.

          ps. I live in Mass where we have an individual mandate and have had it for years.


          "Out of Many, One Nation." This is the great promise of the United States of America -9.75 -6.87

          by Uncle Moji on Tue Oct 29, 2013 at 05:34:29 PM PDT

          [ Parent ]

    •  Many plans are similiar to employer-offered plans (0+ / 0-)

      That deductible is often for major events, but not often for routine care. Very few plans on either the individual or the group (e.g. employer coverage) markets have zero deductibles for all services.

    •  You may wish to study the Massachusetts (3+ / 0-)

      mandate.   We have 97% coverage.  This includes the poor folks you write about.  

      I work in a business where most of us are paid minimum or near minimum wages.  All of us have health insurance coverage.  

      Many of my co-workers qualify for food stamps and fuel assistance and other government subsidies because our wages are so horrible.  And yet, we all have coverage.  And unlike my youth decades ago when I refused to buy health insurance, my young co-workers seem to see it as a normal part of life.  I remain surprised at how normalized the expectation that they pay for (at a subsidized rate) health insurance coverage and go and see the doctor when they are ill.  I would never have guess it, but it's happening.  And as a population, we are healthier for it.  

      I wrote farther down about your misunderstanding about what a deductible is, so I won't go into that, but I think you are wrong about one thing for sure and that is:

      That is NOT how insurance is supposed to work.
      It is, actually, how all insurance works, it is a for-profit ruthless business.  It's not how health care is supposed to work, I agree with that.  But that is not something that most of the country agrees with, yet.  

      "Out of Many, One Nation." This is the great promise of the United States of America -9.75 -6.87

      by Uncle Moji on Tue Oct 29, 2013 at 05:46:22 PM PDT

      [ Parent ]

  •  The People, you know, *voted*. They voted (0+ / 0-)

    for the guy who swore he'd never sign a bill with an individual mandate.

    Argue 'till your lips fall off.  Who cares?

    It was a deceitful bait and switch and people will continue to be pissed about it.

    "But the traitors will pretend / that it's gettin' near the end / when it's beginning" P. Ochs

    by JesseCW on Tue Oct 29, 2013 at 03:04:58 PM PDT

    •  Obama flip-flopped (2+ / 0-)
      Recommended by:
      JamieG from Md, True North

      But he changed his mind when experts confronted him with evidence that the mandate was necessary.

      I kind of like my elected officials to change their mind when they learn new evidence that should make them reconsider positions.

      Also, I suspect a very small portion of the primary electorate preferred Obama over Clinton for that one policy difference. Voters have  a great many reasons for making their decisions like they do.

  •  Individual mandate doesn't bother me (1+ / 0-)
    Recommended by:
    Fake Irishman

    How many people really don't want to have health insurance, even if it is good insurance and they can afford it?

    The group of Americans who have insurance through the private market, and are being over-charged for it, is pretty big.

    The group of Americans who have junk insurance, and thus are under-insured, is also pretty big, as is the group who are completely uninsured. They can't get good insurance because they can't afford it.

    The group of Americans who don't want health insurance, period? Very small, I suspect, though I stand to be corrected

    Those people don't have to buy insurance. Yes, if they file a tax return, and they can afford insurance but don't have it, they will pay a penalty.

    Even when it reaches its maximum in a few years, it will still be less than premiums, for most people.

    I think it is fair for people who choose not to have health insurance to pay a little more on their taxes. As a group, they cost the government more, because, as a group, they use more health care than they can pay for out-of-pocket. The government picks up part of that cost.

    So, they don't have to buy insurance, but they do have to put a little more into the coffers to help offset what the government pays for health care for the uninsured.

    Seems reasonable to me. Think of it as a tax break for people who have insurance, rather than a tax penalty for people who don't.

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